Patient Care-related Activities Research Articles

Strategies Proposed by Students and Pharmacists for Virtual Experiential Patient Care Practicums.

Background: The University of British Columbia (UBC) Pharmacists Clinic (the Clinic) is a pharmacist-led patient care clinic serving as a practice site for experiential education in a team-based primary care practice. Given the unprecedented circumstances surrounding COVID-19, some pharmacy practice sites have permanently transitioned select experiential education activities to a virtual format. Currently, there is limited literature on teaching practices that are conducive to students' success in a virtual environment. Objective: To determine the factors that enable successful development of a virtual patient care practicum experience at a university clinic from the perspectives of student pharmacists and practice educators. Methods: A qualitative research methodology was used to gain the perspectives of student pharmacists, who did not have experience with virtual practicums, and practice educators, who had some experience with virtual practicums at the time of the study. Separate focus group interviews were conducted using a semi-structured approach and consisted of questions aimed at gathering insight into participant perspectives on virtual practicums. The focus group sessions were audio recorded with participant consent and transcribed. A thematic analysis was conducted to analyze the data. Results: Three pharmacist practice educators and three student pharmacists participated in their respective focus groups. Six major themes were developed based on the data: (1) technology optimization, (2) patient care related activities, (3) student-practice educator relationship, (4) student skill development, (5) student support, and (6) in-person vs virtual practicum preferences. Proposed strategies to mitigate the limitations of virtual practicums included setting communication guidelines, arranging enriching learning opportunities, and having reliable internet connection. Conclusion: The participants in this study provided insight on factors to support successful development and delivery of a virtual patient care practicum. The results from this study can be applied to other health disciplines and their approach to virtual practicums during and following the COVID-19 pandemic.

Association of reintubation and hospital costs and its modification by postoperative surveillance: A multicenter retrospective cohort study

ObjectiveWe estimated hospital costs associated with postoperative reintubation and tested the hypothesis that prolonged surveillance in the post-anesthesia care unit (PACU) modifies the hospital costs of reintubation. DesignRetrospective observational research study. SettingTwo tertiary care academic healthcare networks in the Bronx, New York and Boston, Massachusetts, USA. Patients68,125 adult non-cardiac surgical patients undergoing general anesthesia between 2016 and 2021. InterventionsThe exposure variable was unplanned reintubation within 7 days of surgery. MeasurementsThe primary outcome was direct hospital costs associated with patient care related activities. We used a multivariable generalized linear model based on log-transformed costs data, adjusting for pre- and intraoperative confounders. We matched our data with data from the Healthcare Cost and Utilization Project-National Inpatient Sample (HCUP-NIS). In the key secondary analysis, we examined if prolonged postoperative surveillance, defined as PACU utilization (≥4 h) modifies the association between reintubation and costs of care. Main results1759 (2.6%) of patients were re-intubated within 7 days after surgery. Reintubation was associated with higher direct hospital costs (adjusted model estimate 2.05; 95% CI: 2.00–2.10) relative to no reintubation. In the HCUP-NIS matched cohort, the adjusted absolute difference (ADadj) in costs amounted to US$ 18,837 (95% CI: 17,921–19,777). The association was modified by the duration of PACU surveillance (p-for-interaction <0.001). In patients with a shorter PACU length of stay, reintubation occurred later (median of 2 days; IQR 1, 5) versus 1 days (IQR 0, 2; p < .001), and was associated with magnified effects on hospital costs compared to patients who stayed in the PACU longer (ADadj of US$ 23,444, 95% CI: 21,217–25,799 versus ADadj of US$ 17,615, 95% CI: 16,350–18,926; p < .001). ConclusionPostoperative reintubation is associated with 2-fold higher hospital costs. Prolonged surveillance in the recovery room mitigated this effect. The cost-saving effect of longer PACU length of stay was likely driven by earlier reintubation in patients who needed this intervention.

Justifying the use of balanced scorecard in medical colleges to enhance teaching, research, and patient care-related activities

Justifying the use of balanced scorecard in medical colleges to enhance teaching, research, and patient care-related activities

Patterns and Perceptions of Smartphone Use Among Academic Neurologists in the United States: Questionnaire Survey.

BackgroundSmartphone technology is ubiquitous throughout neurologic practices, and numerous apps relevant to a neurologist’s clinical practice are now available. Data from other medical specialties suggest high utilization of smartphones in routine clinical care. However, the ways in which these devices are used by neurologists for patient care–related activities are not well defined.ObjectiveThis paper aims to characterize current patterns of smartphone use and perceptions of the utility of smartphones for patient care–related activities among academic neurology trainees and attending physicians. We also seek to characterize areas of need for future app development.MethodsWe developed a 31-item electronic questionnaire to address these questions and invited neurology trainees and attendings of all residency programs based in the United States to participate. We summarized descriptive statistics for respondents and specifically compared responses between trainees and attending physicians.ResultsWe received 213 responses, including 112 trainee and 87 attending neurologist responses. Neurology trainees reported more frequent use of their smartphone for patient care–related activities than attending neurologists (several times per day: 84/112, 75.0% of trainees; 52/87, 59.8% of attendings; P=.03). The most frequently reported activities were internet use, calendar use, communication with other physicians, personal education, and health care–specific app use. Both groups also reported regular smartphone use for the physical examination, with trainees again reporting more frequent usage compared with attendings (more than once per week: 35/96, 36.5% of trainees; 8/58, 13.8% of attendings; P=.03). Respondents used their devices most commonly for the vision, cranial nerve, and language portions of the neurologic examination. The majority of respondents in both groups reported their smartphones as “very useful” or “essential” for the completion of patient care–related activities (81/108, 75.0% of trainees; 50/83, 60.2% of attendings; P=.12). Neurology trainees reported a greater likelihood of using their smartphones in the future than attending neurologists (“very likely”: 73/102, 71.6% of trainees; 40/82, 48.8% of attendings; P=.005). The groups differed in their frequencies of device usage for specific patient care–related activities, with trainees reporting higher usage for most activities. Despite high levels of use, only 12 of 184 (6.5%) respondents reported ever having had any training on how to use their device for clinical care. Regarding future app development, respondents rated vision, language, mental status, and cranial nerve testing as potentially being the most useful to aid in the performance of the neurologic examination.ConclusionsSmartphones are used frequently and are subjectively perceived to be highly useful by academic neurologists. Trainees tended to use their devices more frequently than attendings. Our results suggest specific avenues for future technological development to improve smartphone use for patient care–related activities. They also suggest an unmet need for education on effectively using smartphone technology for clinical care.

How Physicians Spend Their Work Time: an Ecological Momentary Assessment.

Little is known about how physicians spend their work time. To determine how physicians in outpatient care spend their time at work, using an innovative method: ecological momentary assessment (EMA). Physician activity was measured via EMA, using a smartphone app. Twenty-eight practices across 16 US states. Sixty-one physicians: general internal medicine, family medicine, non-interventional cardiology, orthopedics. Proportions of time spent on 14 activities within 6 broad categories of work: direct patient care (including both face-to-face care and other patient care-related activities), electronic health record (EHR) input, administration, teaching/supervising, personal time, and other. After excluding personal time, physicians spent 66.5% of their time on direct patient care (23.6% multitasking with use of the EHR and 42.9% without the EHR), 20.7% on EHR input alone, 7.7% on administrative activities, and 5.0% on other activities (0.6% using the EHR). In total, physicians spent 44.9% of their time on the EHR. Unable to measure time spent at home on the EHR or other work tasks; participating physicians were not a random sample of US physicians. The efficiency of highly trained professionals spending only two-thirds of their time on direct patient care may be questioned. EHR use continues to account for a large proportion of physician time. Further attempts should be made to redesign both EHRs and physician work processes.

Readiness and Implementation of Quality Improvement Strategies Among Small- and Medium-Sized Primary Care Practices: an Observational Study.

Little is known about what determines strategy implementation around quality improvement (QI) in small- and medium-sized practices. Key questions are whether QI strategies are associated with practice readiness and practice characteristics. Grounded in organizational readiness theory, we examined how readiness and practice characteristics affect QI strategy implementation. The study was a component of a larger practice-level intervention, Heart of Virginia Healthcare, which sought to transform primary care while improving cardiovascular care. This observational study analyzed practice correlates of QI strategy implementation in primary care at 3 and 12 months. Data were derived from surveys completed by clinicians and staff and from assessments by practice coaches. A total of 175 small- and medium-sized primary care practices were included. Outcome was QI strategy implementation in three domains: (1) aspirin, blood pressure, cholesterol, and smoking cessation (ABCS); (2) care coordination; and (3) organizational-level improvement. Coaches assessed implementation at 3 and 12 months. Readiness was measured by baseline member surveys, 1831 responses from 175 practices, a response rate of 73%. Practice survey assessed practice characteristics, a response rate of 93%. We used multivariate regression. QI strategy implementation increased from 3 to 12 months: the mean for ABCS from 1.20 to 1.59, care coordination from 2.15 to 2.75, organizational improvement from 1.37 to 1.78 (95% CI). There was no statistically significant association between readiness and QI strategy implementation across domains. Independent practice implementation was statistically significantly higher than hospital-owned practicesat 3 months for ABCS (95% CI, P = 0.01) and care coordination (95% CI, P = 0.03), and at 12 months for care coordination (95% CI, P = 0.04). QI strategy implementation varies by practice ownership. Independent practices focus on patient care-related activities. FQHCs may need additional time to adopt and implement QI activities. Practice readiness may require more structural and organizational changes before starting a QI effort.

Roadmap to resuming care for liver diseases after coronavirus disease-2019.

The global pandemic of coronavirus disease‐2019 (COVID‐19) has led to significant disruptions in healthcare delivery. Patients with chronic liver diseases require a high level of care and are therefore particularly vulnerable to disruptions in medical services during COVID‐19. Recent data have also identified chronic liver disease as an independent risk factor for COVID‐19 related hospital mortality. In response to the pandemic, national and international societies have recommended interim changes to the management of patients with liver diseases. These modifications included the implementation of telehealth, postponement or cancelation of elective procedures, and other non‐urgent patient care‐related activities. There is concern that reduced access to diagnosis and treatment can also lead to increased morbidity in patients with liver diseases and we may witness a delayed surge of hospitalizations related to decompensated liver disease after the COVID‐19 pandemic has receded. Therefore, it is paramount that liver practices craft a comprehensive plan for safe resumption of clinical operations while minimizing the risk of exposure to patients and health‐care professionals. Here, we provide a broad roadmap for how to safely resume care for patients with chronic liver disease according to various phases of the pandemic with particular emphasis on outpatient care, liver transplantation, liver cancer care, and endoscopy.

Vascular surgery residents spend one fifth of their time on electronic health records after duty hours

ObjectiveElectronic health records (EHR) have largely replaced paper-based medical records. Academic institutions have adapted EHR successfully and technological innovations now allow remote access. Thus, self-reported resident duty hours may not accurately reflect the actual time that is spent on patient care-related activities. MethodsThis retrospective observational study quantified vascular surgery resident EHR activities between January 2016 and June 2016 at a tertiary care hospital. Use time was tracked from user login to logout, divided by day of the week, and separated by EHR tasks performed. Each 24-hour time period was further divided into on-duty (6:00 am to 6:00 pm) and off-duty (6:00 pm to 6:00 am) hours. On-call weekdays and rotations that occurred off campus were excluded. The following EHR activity data were requested: total time, chart review time, documentation time, electronic order entry, patient discovery, and electronic messages. ResultsA total of 11,812 charts were accessed: 80.5% on weekdays and 19.5% on weekends. Total time spent (hours:minutes:seconds, weekday percentage, weekend percentage) on EHR during this time period was 634:33:36 (81.2%, 18.8%). On weekdays, 79% of the EHR time was during the work hours and 21% after hours. On weekends, 78% of the EHR time was during work hours and 22% after hours. Time spent on different EHR tasks was as follows: chart review 278:58:34, documentation 66:33:07, electronic order entry 120:50:24, electronic messaging 2:16:48, problem list modification 1:49:26, electronic messages 4:30:43, patient discovery 151:14:53, and other 164:05:17. Overall, postgraduate year 1 residents spent the most number of hours on EHRs and during the weekdays. There was serial decrease in the total number of EHR hours and the number of weekday hours with the seniority of the residents, with postgraduate year 5 residents spending the least number of overall hours and weekday hours on the EHR. When EHR access was compared with self-reported duty hours, resident compliance was 58% on average. ConclusionsEHR use after hours constituted one-fifth of a vascular surgical trainee's total EHR time. Despite self-reported duty-hour compliance, a good proportion of their daily time is still spent on patient care. This pilot study sets the stage for larger studies to be conducted in future to address this issue.

Physician staffing needs in critical care departments

Departments of Critical Care Medicine are characterized by high medical assistance costs and great complexity. Published recommendations on determining the needs of medical staff in the DCCM are based on low levels of evidence and attribute excessive significance to the structural/welfare approach (physician-to-beds ratio), thus generating incomplete and minimalistic information. The Spanish Society of Intensive Care Medicine and Coronary Units established a Technical Committee of experts, the purpose of which was to draft recommendations regarding requirements for medical professionals in the ICU. The Technical Committee defined the following categories: (1) patient care-related aspects; (2) activities outside the ICU; (3) patient safety and clinical management aspects; (4) teaching; and (5) research. A subcommittee was established with experts pertaining to each activity category, defining criteria for quantifying the percentage time of the intensivists dedicated to each task, and taking into account occupational category. A quantitative method was applied, the parameters of which were the number of procedures or tasks and the respective estimated indicative times for patient care-related activities within or outside the context of the DCCM, as well as for teaching and research activities. Regarding non-instrumental activities, which are more difficult to evaluate in real time, a matrix of range versus productivity was applied, defining approximate percentages according to occupational category. All activities and indicative times were tabulated, and a spreadsheet was created that modified a previously designed model in order to perform calculations according to the total sum of hours worked and the hours stipulated in the respective work contract. The competencies needed and the tasks which a Department of Critical Care Medicine professional must perform far exceed those of a purely patient care-related character, and cannot be quantified using structural criteria. The method for describing the 5 types of activity, the quantification of specific tasks, the respective times needed for each task, and the generation of a spreadsheet led to the creation of a management instrument.

Estimación de las necesidades de profesionales médicos en los servicios de medicina intensiva

Departments of Critical Care Medicine are characterized by high medical assistance costs and great complexity. Published recommendations on determining the needs of medical staff in the DCCM are based on low levels of evidence and attribute excessive significance to the structural/welfare approach (physician-to-beds ratio), thus generating incomplete and minimalistic information. The Spanish Society of Intensive Care Medicine and Coronary Units established a Technical Committee of experts, the purpose of which was to draft recommendations regarding requirements for medical professionals in the ICU. The Technical Committee defined the following categories: 1) Patient care-related aspects; 2) Activities outside the ICU; 3) Patient safety and clinical management aspects; 4) Teaching; and 5) Research. A subcommittee was established with experts pertaining to each activity category, defining criteria for quantifying the percentage time of the intensivists dedicated to each task, and taking into account occupational category. A quantitative method was applied, the parameters of which were the number of procedures or tasks and the respective estimated indicative times for patient care-related activities within or outside the context of the DCCM, as well as for teaching and research activities. Regarding non-instrumental activities, which are more difficult to evaluate in real time, a matrix of range versus productivity was applied, defining approximate percentages according to occupational category. All activities and indicative times were tabulated, and a spreadsheet was created that modified a previously designed model in order to perform calculations according to the total sum of hours worked and the hours stipulated in the respective work contract. The competencies needed and the tasks which a Department of Critical Care Medicine professional must perform far exceed those of a purely patient care-related character, and cannot be quantified using structural criteria. The method for describing the 5 types of activity, the quantification of specific tasks, the respective times needed for each task, and the generation of a spreadsheet led to the creation of a management instrument.

Medical student stories of participation in patient care-related activities: the construction of relational identity.

Professional identity formation is acknowledged as one of the fundamental tasks of contemporary medical education. Identity is a social phenomenon, constructed through participation in everyday activities and an integral part of every learning interaction. In this paper we report from an Australian ethnographic study into how medical students and patients use narrative to construct their identities. The dialogic narrative analysis employed focused on the production of meaning through the use of language devices in a given context, and the juxtaposition of multiple perspectives. Two stories told by students about their participation in patient care-related activities reveal how identities are constructed in this context through depictions of the relationships between medical students, patients and clinical teachers. These students use the rhetorical functions of stories to characterise doctors and patients in certain ways, and position themselves in relation to them. They defend common practices that circumvent valid consent processes, justified by the imperative to maximise students' participation in patient care-related activities. In doing so, they identify patients as their adversaries, and doctors as allies. Both students are influenced by others' expectations but one reveals the active nature of identity work, describing subtle acts of resistance. These stories illustrate how practices for securing students' access to patients can influence students' emerging identities, with implications for their future disclosure and consent practices. We argue that more collaborative ways of involving medical students in patient care-related activities will be facilitated if students and clinical teachers develop insight into the relational nature of identity work.

A Time and Motion Study on the Activities of the Staff Nurses and Health Centre Auxiliaries of a Secondary Hospital in Vellore District

A time motion study was undertaken to study the activities of the Staff Nurses and the Health Centre Auxiliaries in a secondary hospital who were observed for 46.5 hours and 32.5 hours respectively during their day shift work. The staff nurses spent 68.81% of their time in direct patient care related activities. The Health Centre Auxiliaries spent 59.3% of their time in unit related activities. Staff nurses spent significant proportion of their time 11.12% of their time in non clinical activities, whereas the Health Centre Auxiliaries spent 7.3% of their time in non clinical activities. The staff nurses were spending 17.6% of their in documentation, admission procedure 13.9% and administration of medications 13.9%. Staff Nurses spent only 10.82% of their time in assessing the patients. Out of the total working hours 12.92% of the time spent by the Health Centre Auxiliaries was unproductive.

Registered Nurses and Unlicensed Assistive Personnel: An Uneasy Alliance

To meet challenges of continuing change in the health care industry and maintain organizational viability in increasingly competitive markets, the use of the registered nurse--unlicensed assistive personnel model is an undeniable reality that fills the void created by the current shortage of nurses and decreases the costs of providing patient care. Although much has been published about the need for nurses to delegate and supervise patient care-related activities, little has been written about the skills needed to do this effectively or how these skills may be learned. Academic and clinical educators must find ways to facilitate the development of delegation and supervision abilities as nurses increasingly work with nonprofessional staff. Continuing education is an effective way for nurses to learn the skills required by changing models of patient care delivery and evolving professional roles.

Re-engineering of nasopharyngeal aspiration procedures to enhance infection control

BACKGROUND: After the SARS epidemic, standard precautions were enforced in all patient care procedures. Use of personal protective equipment (PPE) was particularly indicated for healthcare workers when they perform patient care related activities that were likely to generate splashes. Nasopharyngeal aspiration procedures (NPA) are well known to be high-risk procedures for which use of PPE is necessary. Traditionally, in performing NPA, staff members stand directly facing the patient which increases the risk of direct droplet or aerosol transmission. Use of NPA, however, is important to guarantee a reliable diagnostic yield (with high specificity and sensitivity), e.g., in investigating suspected SARS and influenza. Re-engineering of procedures involved in NPA was therefore necessary to enhance safety in infection control. METHODS: Reliable and safe approaches to NPA were developed by modifying the positioning based on infection control principles. The staff performing NPA stands either posterior or next to the patient, who looks forward. The basic skills remain unchanged, but with strong emphasis of “clean hand and dirty hand” concept after the specimen is collected in order to avoid environmental contamination. RESULTS: Such practice was demonstrated and introduced to different groups of medical and nursing staff via train-the-trainer programs in early 2004. Subsequent evaluation revealed greatly enhanced staff satisfaction with the new procedures. Re-engineering was an important concept in infection control for review of high-risk patient care procedures. CONCLUSIONS: With increased awareness of the importance of infection control in protecting both staff and patients, re-engineering of some patient care procedures may be needed. The modification of NPA procedures served as a good example for developing such approaches to re-engineering. BACKGROUND: After the SARS epidemic, standard precautions were enforced in all patient care procedures. Use of personal protective equipment (PPE) was particularly indicated for healthcare workers when they perform patient care related activities that were likely to generate splashes. Nasopharyngeal aspiration procedures (NPA) are well known to be high-risk procedures for which use of PPE is necessary. Traditionally, in performing NPA, staff members stand directly facing the patient which increases the risk of direct droplet or aerosol transmission. Use of NPA, however, is important to guarantee a reliable diagnostic yield (with high specificity and sensitivity), e.g., in investigating suspected SARS and influenza. Re-engineering of procedures involved in NPA was therefore necessary to enhance safety in infection control. METHODS: Reliable and safe approaches to NPA were developed by modifying the positioning based on infection control principles. The staff performing NPA stands either posterior or next to the patient, who looks forward. The basic skills remain unchanged, but with strong emphasis of “clean hand and dirty hand” concept after the specimen is collected in order to avoid environmental contamination. RESULTS: Such practice was demonstrated and introduced to different groups of medical and nursing staff via train-the-trainer programs in early 2004. Subsequent evaluation revealed greatly enhanced staff satisfaction with the new procedures. Re-engineering was an important concept in infection control for review of high-risk patient care procedures. CONCLUSIONS: With increased awareness of the importance of infection control in protecting both staff and patients, re-engineering of some patient care procedures may be needed. The modification of NPA procedures served as a good example for developing such approaches to re-engineering.

Work activities before and after implementation of an automated dispensing system.

The impact of an automated dispensing system (ADS) on medication-related work activities by nurses and pharmacists was studied. A point-of-care ADS (Baxter Sure-Med) was installed on two nursing units (the surgical intensive care unit [SICU] and a medicine unit [4NMU]) of a 400-bed university hospital as part of a pilot project. A self-reported work-sampling study was used to collect observations of medication-related work activities by nurses, health unit coordinators (nursing support staff), and pharmacists for a seven-day period before ADS implementation and a seven-day period after implementation. There were 7797 observations of nurse work activities, 1408 observations of health unit coordinator work activities, and 4236 observations of pharmacist work activities. The percentage of nurse work activities that were medication related decreased from 20.7% before ADS implementation to 18.4% afterward on 4NMU and increased slightly from 10.8% to 11.0% on the SICU. Medication-related health unit coordinator work activities increased from 17.5% to 25.3% of total activities on 4NMU and decreased from 16.6% to 10.7% on the SICU. None of these changes was significant. For decentralized pharmacists supporting 4NMU, the percentage of work activities classified as clinical increased significantly from 36.5% to 49.1%. For decentralized pharmacists supporting the SICU, clinical activities increased from 27.9% to 35.1%. There were no significant changes on either unit in pharmacist activities classified as technical. An overall measure of the efficiency with which pharmacists used their time for patient care-related activities increased. A point-of-care ADS did not affect the proportion of time spent by nurses on medication-related activities and seemed to give pharmacists more time for clinical work.

Work activities of pharmacy teams with drug distribution and clinical responsibilities.

The time spent by satellite pharmacists and technicians on various activities was measured by using work sampling to evaluate the pharmacists' use of time for patient care. Between December 1992 and April 1993, pharmacists and technicians on satellite pharmacy teams at a tertiary care teaching hospital reported their work activities on forms. A total of 11,485 observations of pharmacist work activities and 7,626 observations of technician work activities were made. Pharmacists on teams with fewer support staff members spent less time on patient care-related work activities, and vice versa. As measured by an institution-specific index, the efficiency with which pharmacists used the available work time for patient care ranged from 60% to 83% for the various teams (100% would mean that pharmacists spent all their work time on patient care tasks). Changes were made in technician staffing that enabled the pharmacists to devote more time to patient care. Measuring the time pharmacists and technicians spent on various work activities provided a means of identifying and correcting organizational inefficiencies in order to give the pharmacists more time for patient care.